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The Behavioral Determinants of Exercise PDF
The Behavioral Determinants of Exercise PDF
The Behavioral Determinants of Exercise PDF
CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CHAPTER PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DIFFERENTIATING BETWEEN EXERCISE ADOPTION,
MAINTENANCE, AND RELAPSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
PERSONAL CHARACTERISTICS ASSOCIATED WITH
PHYSICAL ACTIVITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Self-Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Stage of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Exercise History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Body Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Health Risk Profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ENVIRONMENTAL CHARACTERISTICS ASSOCIATED WITH
PHYSICAL ACTIVITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
0199-9885/00/0715-0021$14.00 21
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Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Attributes of Exercise Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
INTERACTION OF PHYSICAL ACTIVITY DETERMINANTS . . . . . . . . . . . . . . 31
Summary and Implications for Physical Activity Promotion
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Motivation for Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Self-Efficacy for Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Readiness for Physical Activity Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Barriers to Physical Activity: Time and Access . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Enhancing Social Support for Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . 36
Environmental Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
SUMMARY AND CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
INTRODUCTION
A physically active lifestyle has many benefits, including reduced risk of coro-
nary heart disease, hypertension, colorectal cancer, obesity, and osteoporosis
(10, 11, 14, 70). Benefits also include reduced stress and depression and increased
emotional well-being, energy level, self-confidence, and satisfaction with social
activity (43). Benefits of physical activity are evident at low- as well as high-
intensity activity levels (19, 39, 69, 90, 91, 99). Indeed, some have argued that the
greatest potential for health benefits would accrue by having sedentary adults be-
come moderately active (17, 93, 97). Physical activity appears to confer substantial
benefits at any age and regardless of prior physical activity history.
Despite the well-documented health benefits of physical activity, current esti-
mates suggest that we are in the midst of an epidemic of sedentary behavior. Mech-
anization of work and of many domestic chores has, for the most part, eliminated
obligatory physical activity from modern life. Voluntary physical activity, also
called recreational physical activity, has thus assumed central importance in filling
physical activity needs and is the focus of this chapter. Unfortunately, however,
voluntary physical activity is not popular. Only 22% of adults report engaging
in regular physical activity, i.e. a minimum of 30 min of moderate-to-vigorous
activity on most days of the week, the activity level most recently recommended
by the American College of Sports Medicine, the Centers for Disease Control and
Prevention, and others (123). Some 25% of adults report that they never engage
in physical activity during leisure time.
The prevalence of regular physical activity varies according to demographic
characteristics. Men are more physically active than women (16). Only 40% of
American women participate in any form of regular physical activity (17, 18). Par-
ticipation in regular activity declines with age, with women experiencing a greater
decline in older age groups than men (18). African American and Hispanic adults
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are less physically active than Caucasians (17, 123). Education and income are
also both positively associated with physical activity level (6, 16, 38, 56). Marital
status is also related to physical activity level. Unmarried people are the most
active and married women the least (123). These demographic differences sug-
gest that barriers and preferences for physical activity likely vary across different
population subgroups and are factors that need to be understood in developing
programs to increase physical activity.
CHAPTER PURPOSE
In light of the well-documented health benefits of physical activity and the fact
that the majority of adult men and women are inactive, promoting regular physical
activity is a public health priority. The goal of the chapter is to review current
research findings regarding the determinants of exercise behavior and to discuss
(a) the implications of this knowledge for individual and public health recom-
mendations and (b) intervention strategies for promoting physical activity. The
discussion is predicated on the belief that physical activity is a complex, dynamic
process. During their lives, individuals typically move through various phases of
exercise participation that are determined by diverse factors (81, 84, 108). This
chapter discusses physical activity determinants in two broad categories: indi-
vidual characteristics such as motivations, skills, and other health behaviors; and
environmental characteristics such as access, cost, and social and cultural supports.
A recurrent theme in most recent discussions of physical activity is complexity,
e.g. multiple pathways to change (5); tailoring of interventions with regard to in-
dividual, environmental, and cultural characteristics; and increasing recognition
that the determinants of physical activity at initiation, maintenance, and relapse
may differ (73). An attempt is made to capture this complexity in the review.
24 SHERWOOD JEFFERY
Self-Efficacy
Among the psychological correlates of exercise that have been examined, exercise
self-efficacy is the strongest and most consistent predictor of exercise behavior.
Self-efficacy predicts both exercise intention and several forms of exercise behav-
ior (12, 20, 29, 47, 48, 75, 77, 80, 83, 95, 96, 104). Self-efficacy is an individuals
belief in his/her capability of executing the courses of action necessary to satisfy sit-
uational demands. It is theorized to influence the activities that individuals choose
to approach, the effort expended on such activities, and the degree of persistence
demonstrated in the face of failure or aversive stimuli (4). Exercise self-efficacy is
the degree of confidence an individual has in his/her ability to be physically active
under a number of specific/different circumstances, or in other words, efficacy
to overcome barriers to exercise (29). Self-efficacy is thought to be particularly
important in the early stages of exercise (80). In the early stage of an exercise
program, exercise frequency is related to ones general beliefs regarding physical
abilities and ones confidence that continuing to exercise in the face of barriers
will pay off. Individuals with greater self-efficacy are more likely to adhere to
exercise programs with sufficient regularity to reach a point where the behavior
has become, to a certain extent, habitual.
Stage of Change
The transtheoretical model and its application to a wide range of health behaviors,
including physical activity, has received considerable recent attention (25, 102).
The transtheoretical model is an integrative model for understanding how people
progress toward adopting and maintaining health behavior change. Core features
of the model are the five stages of change and the processes of change. The trans-
theoretical model views change as a process involving progress through a series of
stages, including precontemplation, contemplation, preparation, action, and main-
tenance. Processes of change are the strategies people use to progress through
the stages (100). Research has shown that individuals can be easily staged for
exercise (64, 76), that exercise stage is associated with exercise level (78), and that
the psychological and behavioral correlates associated with stage of change for
physical activity and with transitions from one stage to another are similar to those
seen in other health behaviors (76, 79). Assessing stage of change for exercise,
thus, provides some useful descriptive information regarding physical activity.
The predictive utility of stage of change for exercise is less clear. However, initial
research examining the efficacy of stage-matched interventions suggests that this
may be a promising strategy (72).
Exercise History
Prior history of physical activity should positively influence future physical activity
behavior by promoting and shaping self-efficacy for exercise and by developing
physical activity skills. The observed relationship between exercise history and
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Body Weight
Body weight is a strong correlate of physical activity. An abundance of cross-
sectional research shows that heavier individuals are less active than lighter indi-
viduals, and prospective research indicates that changes in physical activity level
are associated with changes in body weight in the direction predicted by the energy
balance equation (23, 26, 37, 41, 44, 47, 62, 115, 124, 125). Exercise has also been
shown to improve short- and long-term weight loss in experimental studies (62).
Clearly, body weight and physical activity are inextricably linked. The extent
to which weight status is a barrier to physical activity, a consequence of physical
activity, or a motivating factor for initiating activity is unclear. Heavier individ-
uals may be more sedentary than lighter-weight individuals in part because, for
heavier people, physical activity is less pleasurable and in part because of the
embarrassment heavier people feel about being seen in public in exercise clothes
(46). However, weight status can also be a motivator for initiating exercise. One
of the most common reasons individuals give for exercising is weight control, and
dieting to control weight is positively associated with frequency of participation
in both high- and moderate-intensity physical activity (41).
exercise patterns and are less likely to initiate an exercise program (46). Cigarette
smoking may be thought of as a barrier to physical activity because it has a dis-
ruptive effect on physical activity performance; exercise is easier for nonsmokers
than for smokers. Some researchers have begun to examine physical activity as a
gateway for smoking cessation. Should smokers interested in quitting smoking be
encouraged to start an exercise program? Does engaging in regular physical activ-
ity help individuals avoid smoking and/or do changes in smoking status influence
changes in physical activity level? One recent study randomized women smokers
to either a cognitive-behavioral smoking cessation program or the same program
and a vigorous exercise program (71). Results indicated that smokers who partic-
ipated in the physical activity program were approximately twice as likely to be
abstinent from smoking from posttreatment through 3 months of follow-up.
Diet
Active adults generally have healthier diets than do sedentary adults. Given the
energy requirements of physical activity, chronic moderate-level exercise is nec-
essarily associated with increased energy intake (8). However, physically active
adults tend to eat diets lower in fat compared with their sedentary counterparts
(47, 48). In their discussion of some of the mechanisms through which eating and
exercise behavior might interact with one another to positively influence health,
King & Tribble (62) raised the issue that the impact of exercise on appetite and
eating behavior may vary according to body weight. Exercise often is associated
with a decrease in appetite (33), particularly in the short term, and some studies
have demonstrated no change in food intake with exercise in heavier individuals
(128). For those who have difficulty managing their weight, exercise may provide
a healthy behavioral alternative to overeating. Moreover, exercise also has positive
effects on mood, which may help support decreases in energy intake as well.
Stress
High levels of stress may be associated with poor health behavior patterns, in-
cluding lower levels of physical activity (2). Cross-sectional research indicates
that those who engage in higher levels of physical activity report lower levels of
perceived stress (1). Research also suggests that physical activity has a positive
impact on mood and stress level (42, 103, 116, 129). Stress levels are not static
and must be considered dynamic processes that interact with individuals cop-
ing responses to produce behavioral outcomes. Stetson et al (117) conducted a
prospective evaluation of the effects of stress on exercise adherence, which is a
good illustration of the dynamic interaction between personal, environmental, and
behavioral domains. The study examined the impact of stress on exercise behav-
ior in a sample of female exercise maintainers. Despite the fact that the majority
of women in the sample were regular exercisers, most had reported at least one
exercise relapse in the past, and on average, participants omitted nearly 1 day per
week of planned exercise during the study period. This finding was consistent with
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other literature suggesting that even regular exercisers may stop and start bouts of
regular activity and that exercise adherence may vary on a day-to-day basis. Mi-
nor stress appeared to significantly disrupt exercise adherence and exercise-related
cognitions. Perceived stress had the greatest impact on exercise behavior. The
authors raised the possibility that planned exercise may itself be a minor stres-
sor during periods of ongoing stress. If this is the case, it may be misleading to
recommend exercise as a stress management tool in all cases. Missing planned
exercise sessions may result in frustrations and dissatisfaction and decreased ex-
ercise self-efficacy. Further understanding of the dynamic relationships between
stress and exercise initiation, maintenance, relapse, and resumption would be help-
ful for informing interventions and developing strategies to help individuals cope
with barriers to exercise that are associated with high stress levels, such as time
pressure.
Social Support
Social support is another robust correlate of physical activity. Individuals who
engage in regular exercise report more support for activity from people in their
home and work environments (47, 48, 61). Exercise starters are more likely to
perceive their families as being supportive of their desire to maintain good health
(46). Additionally, individuals who joined a fitness program with their spouse
had higher rates of adherence at 12 months compared with those who joined
without a spouse (126). In a comprehensive review, Carron et al (15) examined six
major sources of social influence on physical activity, including such important
others as physicians or work colleagues, family members, exercise instructors
or other in-class professionals, coexercisers, and members of exercise groups.
The authors concluded that social influence generally has a small-to-moderate
effect. Effects that were moderate to large were found for (a) family support and
attitudes about exercise, (b) task cohesion, and adherence, (c) important others
and attitudes about exercise, and (d ) family support and compliance behavior. It
should also be recognized that the relationship between physical activity and social
support is a dynamic process in which sources of social support may change over
time and through the phases of adoption and maintenance of this health behavior
(89). Research also suggests that there may be gender differences in the effect
of social influence on physical activity (56). Troped & Saunders (122) examined
gender differences in social influence on physical activity for men and women
in various stages of exercise adoption. They found that women reported greater
motivation than men to comply with most people, my regular doctor, spouse,
and parents. Gender differences in normative beliefs and social influences were
more pronounced at earlier stages of exercise adoption.
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Time
Time constraints are the most frequent barriers to exercise, reported by both seden-
tary and active individuals (28, 61). It has been suggested that as people establish
a pattern of adherence to various health-promoting behavior, less-deliberate deci-
sion making about adherence occurs and behavior becomes more habitual (68).
However, scheduling efficacy remains an important and significant predictor of
adherence even among regular exercisers (29). Therefore, to maintain exercise
adherence, regular exercisers have to become adept at dealing with time as a bar-
rier. The time barrier may be a particular problem for certain population subgroups.
For example, Schmitz et al (112) reported that becoming a parent is associated
with reductions in physical activity for mothers. Time spent caring for children
may be interfering with attempts to maintain physical activity levels.
Access
Another environmental barrier that has received some attention in the determinants
literature is access to exercise facilities. One way of assessing this has been to
examine whether the distance between individuals homes and exercise facilities
is correlated with exercise behavior (111). It appears that there is a modest re-
lationship between access to facilities and physical activity. Access to exercise
facilities may be related to exercise levels for some individuals but not for others,
depending on activity preference. For those individuals who prefer exercises such
as walking or running, which can be done anywhere, access to facilities may be
less relevant. Additionally, for those who exercise with home equipment, which
could include stationary bikes, treadmills, and even exercise videos, access to fa-
cilities may also not affect exercise adherence. Regardless, the extent to which
environments are conducive to physical activity (i.e. walking/biking paths, safe
streets) likely has a strong impact on population activity levels. One recent study
examining the association between neighborhood safety and sedentary behavior
in a population-based sample found that there was a lower prevalence of physi-
cal activity among persons who perceive their neighborhoods as unsafe. Better
measurement of environmental resources for physical activity and strategies for
improving access to physical activity facilities are needed.
Another aspect of location related to exercise initiation, adherence, and relapse
concerns whether activities are group based or individual. Initial advantages of
group exercise, such as group support and structure provided by these options,
may be outweighed by the long-term costs involved in traveling to exercise sites
at specific times for physical activity involvement (54). There is some indication
that individuals, regardless of current exercise status, are more likely to report a
preference for physical activity that could be performed on ones own rather than
with others in a group or class (61). In a population-based weight-gainprevention
trial, individuals were given opportunities to participate in both home-based and
face-to-face exercise program options. One face-to-face option included a free
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suitable for those initiating physical activity. Research suggests that multiple
short bouts of exercise have been effective at promoting short-term adherence
(51). When compared with a home-based continuous or long-bout exercise pro-
gram with a strong behavioral component, a short-bout program was comparable
with regard to exercise adherence (52). Andersen et al (3) and Dunn et al (31)
each compared a structured exercise program to a lifestyle exercise program that
emphasized the accumulation of at least 30 min of moderate-intensity physical
activity on most days of the week. Unfortunately, however, the published reports
did not provide information regarding the duration and timing of the exercise bouts
for each of the groups, so the effect of multiple versus continuous bouts of activity
could not be assessed.
Injury
Despite the numerous health benefits that exercise confers, regular physical activity
increases risk of musculoskeletal injuries. It is surprising that, with the exception of
injury risk associated with running, there has been relatively little research in this
area (66, 67, 92). Injury risk associated with running is quite high (35%65%) and
increases with running frequency and injury history (92). A recent study examined
injury rates from a variety of moderate-intensity activities and found that injury
rates associated with walking, gardening, outdoor bicycling, aerobics, and weight
training are relatively low (98). We need to understand more about frequency and
adverse effects of injury to better inform exercise initiators, consistent exercisers,
and those who are reinitiating exercise after a relapse about injury prevention. For
those who are initiating exercise programs, we need to learn more about the best
way to become more physically active while preventing injury. The low injury risk
associated with walking, in particular, appears to be another reason to endorse this
favored form of exercise (98). We also need to learn more about the best way to re-
main injury free while engaging in a consistent exercise program. Although some
research has addressed the issue of injury-prevention strategies such as stretch-
ing (49, 92), systematic examination of relationships between injury-prevention
strategies and injury outcome in representative samples of exercisers is necessary.
Possible strategies for preventing injury that successful exercise maintainers may
practice are avoiding exercise burnout and injury by not overtraining, engaging in
stretching, flexibility, and strength training, and cross training. Moreover, since
injury is a major cause of exercise relapse (110), we need to learn more about the
best strategies for avoiding reinjury when resuming exercising.
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activity interventions to assist with mood management and stress levels for specific
populations at risk. For example, King & Brassington (57) discuss adapting phys-
ical activity programs for adult family caregivers, a population at high risk for
negative health behavior patterns and stress levels. Physical activity programs
have also been shown to be an effective strategy for alleviating depression (86).
36 SHERWOOD JEFFERY
potentially more likely to engage in the type and amount of vigorous activity that
would be associated with the greatest health benefits.
Environmental Strategies
A supportive environment is a prerequisite to adequate physical activity levels.
People often cite access as a barrier, and both correlational and experimental data
suggest that access is important (35, 50, 106). Not all attempts to enhance physical
activity by reducing access barriers have been successful, but the preponderance
of evidence supports the idea that public and private (e.g. work sites) support for
physical activity facilities is beneficial. In addition to modifying environments to
promote physical activity, attention should be paid to modifying environments to
reduce access to sedentary behaviors (35). Better measurement of environmen-
tal resources for physical activity and strategies for improving access to physical
activity facilities are needed. In recent years, more attention has been paid to devel-
oping environmental and policy interventions to promote physical activity (106).
Prominent among the strategies suggested are developing better walking/biking
paths for the purposes of both recreation and transportation to work, making work
sites more conducive to physical activity by providing incentives and facilities to
promote exercise (e.g. subsidizing health club memberships and providing show-
ers/dressing rooms for those who commute to work by walking or biking).
Another way in which the environment has an impact on population physical
activity levels is through its influence on social norms and knowledge regarding
physical activity (106). Research examining the impact of mass media campaigns
on physical activity levels has shown that these campaigns have limited effective-
ness (74). More research is needed to know the most effective way to communicate
public health messages regarding the importance of physical activity and strategies
for incorporating exercise into ones lifestyle. Although many people know about
the importance of exercise, there may be misconceptions about exercise (i.e. you
have to be an athlete or engage in vigorous activity to achieve health benefits).
As more research is conducted on alternative ways to obtain health benefits from
physical activity, results should be communicated to the public. We need to ensure,
however, that our public health messages are based on strong empirical findings.
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Without modifying the environment and cultural milieu regarding physical ac-
tivity, efforts targeted toward getting individuals to change behavior will be less
effective.
ACKNOWLEDGMENTS
This work was supported by the National Institute of Diabetes and Digestive and
Kidney Diseases, grant number DK50456, and by the National Heart, Lung and
Blood Institute, grant number HL41332.
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